Abstract
This essay explores the answer to the question whether a UN Convention regarding the protection of the rights of mentally ill patients is needed. Through a historic overview some of the most important national Acts are mentioned and the current international law is further analyzed. Subsequently, through the case study of Pasung in Indonesia, more concerns are rising regarding the violations of the rights of the mentally ill, the adaptation of the mental health notions and the international law to the different cultural backgrounds of the member states. As a conclusion, there is an attempt by the author to answer the initial question of the need of a UN Convention for the mentally ill individuals.
1. Introduction
Through the history of mental health medicalization, it appears that the meaning and interpretation of madness was the foundation of the socially, institutionally and constitutionally formation of psychiatry. Madness, as the deviation from the normative standards, was never interpreted as something that should be constitutionally limited and medically treated, until very later on the history. In fact, by the 5th century CE the distinguish between cognitive impairment and mental illness was already achieved by the medical thinkers of that time and by the 2nd and 3rd century CE cognitive and mental disabilities were recognized both in medicine and in law. The earliest legislation that refers specifically to mental disorder is the statute de Praerogatia Regis of the late thirteenth century in England, which legally distinguishes the “natural fool” and “anyone who formerly having memory and understanding is no longer in his right mind” (Noble, 1981). The intellectual capacity of one to understand the social life and integrate in it, was the common characteristic that mental and cognitive disabled people shared and that is why they were often treated the same by the law during the middle ages. For example, in ancient Rome, the law was focused on the functionality of the person and if they were pursued as incapable they were precluded from certain rights, such as making a will, having or inheriting property, or stipulating (Berkson, 2006).
Until the eighteenth century, it can be commented that the law was actually more in favor of the protection of the property than the protection of the mentally ill person. The rights of the mentally ill were not secured and the community itself, especially the local church, and the family was responsible for taking care of the deviant person. Only in some cases they were marginalized in some special houses, like for instance the “dolhuysjes” in the Netherlands (Abma, 2004). Until 1800 C.E., due to the fact that the evolution of sciences, and especially medicine, did not had yet started to interfere the social constructions of life, there was no institutionally organized system for the treatment of madness. In the eighteenth century though the development of institutional care, through the establishment of the asylums, led to a new form of legislation. The only legislation at that time regarding the inspection of the asylums, both public and private ones, was the 1774 Act for Regulating Private Madhouses. Although the abuse and the horrible medical ‘treatments’, the asylum residents were going through, the civil society and the different national governments were alerted after the wrongful detention of Turlington, in 1761 and Clarke, in 1762. The most important legislation at that time was the Lunatics Act of 1845, which established an inspection body, the Commissioners of the Lunacy, that were responsible for the improvement of the asylums, by overseeing their function and clarifying the procedures for admission and certification (Noble, 1981).
The impressive expansion of the psychiatry, as a result of the desire for a more effective treatment and management of the mentally ill, led to a social movement for the rights of the asylum residents. The first social mental health company was founded in 1908 and the first National Committee for Mental Hygiene in 1909, on initiative of a former asylum patient, Clifford Wittingham Beers, in the United States of America (U.S.A.). Clifford Wittingham Beers was the founder of the American mental hygiene movement, a social movement aimed to launch a campaign for the prevention of mental illness, since it was considered the biggest enemy for the individual, the community and the nation (Cohen. 1983). More and more social movements arose during the twentieth century, as the psychiatry, as a medical science, was fast developed and the victims of World War I and World War II were very much traumatized and needed psychological care. One of the most significant national legislation of that time was the Italian Mental Health Act, or Law 180, which was approved in 1978. This Act represents the beginning of an alternative psychiatric treatment, with dignity and respect to patients. The shift from the asylums and the outdated psychiatric hospitals to an alternative psychiatric care, the one of the community mental health centers was much needed in the Western world, especially after the catastrophic consequences of the World War II (De Fiore, 2018).
The end of World War II was a huge milestone for the protection of human rights and consecutively the rights of the mentally ill. The first international document that included the protection of the rights of all disabled people was the Universal Declaration of Human Rights in 1948: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.” (United Nations Universal Declaration of Human Rights, 1948). It is important to stretch out that this document is not legally binding for the member states and does not make any further clarification on the definition of disability and mental health.
The distinction between mental illness and cognitive disability is something flux even today. Even though the legislation regarding the protection of human rights has been globalized and more accurate, mental health is still very much “Western” and a field that needs to be further explored. No International Convention on the protection of the rights of the mentally ill exists (yet?), but many other legally binding treaties include specific articles in their bodies regarding the protection of these rights. Is this enough though?
2. The international Human Rights law in the field of mental health today
The first international human rights law that protects the rights of the mentally ill is the Convention on the Rights of Persons with Disabilities (CRPD), which was adopted by the UN General Assembly in 2006. It is acceded or ratified by 182 countries up to date. The Convention determines that “Persons with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others.” (United Nations Convention on the Rights of Persons with Disabilities: resolution, 2007a). No other definition is given regarding the difference between people with mental disabilities and people with intellectual impairment.
This Convention is very important since it is a legally binding treaty, which means that the states that have signed it, have a legal obligation to take all the appropriate measures to eliminate discrimination against disabled people and promote their well – being. The right to have access to quality health care services, to be included in the community, to live independently (United Nations Convention on the Rights of Persons with Disabilities: resolution, 2007b) to be equal recognized before the law and to have legal contracts and economic affairs (United Nations Convention on the Rights of Persons with Disabilities: resolution, 2007c) are all key issues in the life of mentally ill people and are recognized by the Convention. Moreover, by promoting the political and social inclusion of the mentally ill, the Convention provides a legal framework for eliminating the stigma associated to mental disabilities (World Health Organization, 2007).
Another important international treaty is the Convention 111, or The Discrimination (Employment and Occupation) Convention, which was adopted by the General Conference of the International Labor Organization in 1958 and has been ratified by 175 countries up to date. This treaty protects workers with disabilities from all forms of discrimination, although a specific definition on disability is not provided. Specifically the convention refers to “. . . persons who, for reasons such as sex, age, disablement, family responsibilities or social or cultural status, are generally recognized to require special protection or assistance, shall not be deemed to be discrimination.” (International Labour Organization Discrimination (Employment and Occupation) Convention, 1958). By not specifying the term ‘disability’, it broadens its provisions to apply to mentally ill people as well.
The International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on Economic, Social and Cultural Rights (ICESCR), both adopted by the UN General Assembly in 1966 and as of today they have 173 and 171 parties respectively. The ICCPR prohibits distinction of any kind and equal treatment in legal systems (United Nations International Covenant on Civil and Political Rights, 1966) and the ICESCR identifies the rights to health care, education, employment and housing for all individuals without any form of discrimination (United Nations International Covenant on Economic, Social and Cultural Rights, 1966).
Finally, the Principles for the Protection of Persons with Mental Illness and the Improvement of Mental Health Care is a UN body of non legally binding principles, that was adopted by the UN General Assembly in 1991. It is the only UN document that it is exclusively referring to the rights of mentally ill people. It provides basic standards regarding the operation of mental health systems and the rights that people with mental disorders should have. It invites all states to respect and apply the rights of the mentally ill as they are protected by the different, legally binding, UN International Conventions.
3. Violations of mental ill patients’ rights; the case of Pasung in Indonesia
“Pasung is the practice of shackling and confining people with mental health conditions at home because of the misconception that they are physically aggressive or dangerous. Some people believe it is because they are possessed by demons. They are forced by their families and society to stay in isolated rooms, bound with chains and wooden beams, all day long and all year round. They eat, drink, urinate and defecate in place. It is still a common practice in Indonesia.” (Andrina, 2021). This passage was published in June 2021 in the website of the United Nations, which means that even today mental health care systems around the world do not offer services with dignity and respect to the patients. The Human Rights Watch found evidence of shackling in 60 countries and only a handful have laws, policies or strategies that explicitly ban or aim to end shackling of people with mental health conditions (Human Rights Watch, 2020). Indonesia is one of these cases, where the practice of shackling still exists.
Pasung remains a common practice in Indonesia and affects the quality of patients’ life and their families. In Indonesia, especially in rural areas, there are still many misconceptions around mental health. Mental disorders are considered a curse and a mystical phenomenon. Incurability, incapability of sustaining legal rights, aggressiveness, and being a public danger, are all characteristics that are strongly attached to people with mental disorders, and this stigma reinforces the brutal practices of restrain and seclusion. Pasung is often seen as an act of purification from the future possible aggressiveness of the mentally ill; it is a sacrifice that has to be made for the greater good. The socioeconomic stratification, though, forces this sacrifice only to the lower socioeconomic levels, that do not have the financial ability to provide proper mental health care services to their family members (Saribu & Napitulu, 2009).
There are many legislative efforts from the state to end this practice, but the achievement seems to be far from the expectations. As early as in 1966, the government legislated the right to mentally ill people to be treated and medicated in a health care facility and in 1977 the Department of Domestic Affairs sent a Ministerial Letter to all national communities asking for a refrain of the practice of pasung. Mentally ill patients had to be delivered in the hospitals and not be kept in captivity in the houses. In 2010, quite many years later, the Gerakan Bebas Pasung (GBP) or Freedom from Pasung of Mentally Ill Persons movement was initiated by the Ministry of Health,, and is now co-led by the Ministry of Health and the Ministry of Social Welfare as well. This movement had a great impact in the civil society; it motivated the religious and academic community in Indonesia to follow its principles, in order to declare a pasung – free Indonesia by the end of 2019. This goal wasn’t achieved. The year 2014 seems to be a milestone, since the National Mental Health legislation was enacted and the practice of pasung , and any other violent act against people with mental disorders, were rendered illegal. No stipulation of pasung as a punishable act was decided, though (Saribu & Napitulu, 2009). The efforts continued and in 2017 the Ministry of Health enacted the Regulation Tackling the Forcible Restraint of People with Mental Illness, in order to create an explicit connection between the elimination of pasung and the formation of an integrated mental health system. Today, 32 out of 34 Indonesian provinces have taken measured aiming to locate, set free, and provide appropriate care to victims of pasung (Hunt, Guth, & Setiyawati, 2021). Moreover, a greater number of general practitioners are educated to provide mental health services and the capacity of clinical psychologists, psychiatrists and mental health nurses is increasing. Although some provinces have been declared pasung – free, there are still pasung cases that are reported (Smith, Marsha, & Waisnawa, 2018).
Regarding the international law, Indonesia has ratified the International Covenant on Civil and Political Rights in 2005, the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment in 1998, the International Covenant on Economic, Social and Cultural Rights in 2005, and the Convention on the Rights of Persons with Disabilities in 2011. All these treaties include, in one way or another, the rights that are violated by the practice of pasung, and in general the rights of the mentally ill. Indonesia, as a member state has an obligation to take all the appropriate measures to end this practice in its province. In its report to the Committee on the Rights of Persons with Disabilities in 2017, Indonesia acknowledges the understaffed mental rehabilitation institutions and mentions that there are only 3 professional health workers per 100.000 population and 26 mental health institutions. It is a challenge for the state not only to eliminate the practice of shackling but also to ensure that pasung – free patients are not re – shackling again (United Nations Committee on the Rights of Persons with Disabilities, 2017).
The common consensus among people regarding the necessity of pasung, along with the absence of an explicit regulation that clearly states the word pasung and prohibits its practice, and the denial of Indonesia to sign the Optional Protocol of CRPD, that gives space for individual complaints, are some of the reasons why this violation on the rights of the mentally ill still remains (Saribu & Napitulu, 2009). Moreover, shackling has a negative impact on people with mental illness, because it can cause trauma, a feeling of abandonment and being inferior and hopelessness (Yulis, Hardianti & Rasmawati, 2021). After setting free of pasung, people face social adaptation problems due to the bio – psychological changes (Novy Helena, Daulima & Yulia Wardani 2018) and the exacerbating stigma (Adeosun, Adegbohun, Jeje & Adewumi, 2014) . Although acceptance and support is given by the families, adapting to the environment might be a crucial problem since the care needed cannot be given by the community only. The objective and subjective burden is huge for the families and many turn back to the familiar practice of re – shackling the mentally ill people.
4. The difficulty of a culturally universal mental health and a culturally competent international law
One of the major challenges in the formation of an international treaty is cultural relativity. But when it comes to a mental health convention this challenge is doubled; the definition and clarification on what is mental health, who is considered mentally ill, what kind of treatment should receive and how mental health can be researched, are all issues differently answered across the world. Cultural norms are dominant in the political, legal and public life and have to be seriously considered, although it is almost prohibited in some countries for an international convention to intervene the public and domestic life.
Regarding the mental health conceptual framework, the universality of the western diagnostic manuals, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (American Psychiatric Association. 2013)., and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) (World Health Organization, 1992), is usually considered indisputable; this means that the client’s behavior, demeanor and way of talking are probably going to be matched against the ICD and DSM criteria and the mental health professionals are going to be trained acording to these standards. This statement can be justified through the WHO studies about the universality of two major diagnostic categories, depression (Sartorius, Jablensky, Gulbinat, & Ernberg, 1980) and schizophrenia (Jablensky, Sartorius, Ernberg, Anker, Korten, Cooper, Day, & Bertelsen, 1992), because the sample was not sufficient, the methodology was generated from Western notions on what is depression and schizophrenia, the tools were not weighted for each country measured, and the results highlighted the universality, while the differences in the manifestations of the disorders that were observed, were dismissed as “relatively minor” (Sartorius et al., 1980, p. 748).
Is this high reliability across cultures accurate? Probably not. The methodology used by the WHO researchers was an etic approach, while an emic/ethnographic approach would be more appropriate, since the local illness categories would be studied overtime within a culture in groups of similar patients. The DSM though recognizes that there are different interpreted disorders across cultures, but, because they are not universal, they exist under the category of “culture – bound”, which is perceived as equally “scientific” as the other categories (Patel, & Winston, 1994).
The problem with this “forced” universality of the Western interpretations regarding mental health is that, when a diagnosis is applied and it does not match the cultural background of the client, it is empty of meaning for the patient and it can lead to an inappropriate treatment. For instance, in the case described by Andary, Stolk and Klimidis (2003), the patient believed that the causation of his problems were supernatural (be bewitched), but that was interpreted as a symptom, leading to a wrongful pathologicalization and a wrongful, over – medicated treatment, which didn’t have any result. When he searched for a culturally appropriate treatment, his condition improved significantly. The ignorance of the cultural background and the persistence to a wrongful treatment, could be interpreted as a violation of some core human rights, due to the under – utilization, when the needs are unmet, and the over – utilization, when some groups are considered in greater distress or are being given more severe diagnoses, than needed (Whaley & Davis, 2007). On the other hand, it can be argued that the practice of shackling is also a culturally derived practice, and it must be examined with another, maybe more reluctant perspective. The counter argument here is that pasung is actually the result of a socio – economic oppression, where medical care is too expensive and in many cases too urbanized to be reach out. The short conclusion to this, is the failure of the state to provide a life, in which people can live with dignity and are not discriminated, due to their economic status and area of residence, from mental health services.
A cultural competent international law is not an easy task either. There are scholars that argue that the UN Conventions are highly westernized; the emphasis on the rhetoric and practice of human rights is mostly individual oriented, the perspectives of the UN makers do not reflect the needs of the ordinary, under-privileged people, the treaties can be contradicting for certain, local, cultural and social values, usually in the Africa and Asia regions and they may be interpreted as Western cultural impositions by some states (Le, 2016) . A Eurocentric prototype is dominant and the non-European countries are seen as the “other”, the inferior, the “savage”, that their citizens need to be saved and protected (Mutua, 2001).
This intersection of a Westernized mental health understanding and a Westernized human rights international law, gives little space to Southern cultures to be seen, and to be taken into consideration. After all, mental health is an under – researched scientific discipline in the West, let alone in the whole other world.
5. Conclusion: Is there a need for a UN Convention?
The importance of a mental health legislation is undeniable. A mental health legislation can set clear, specific and objective boundaries on the definitions of the terms mental illness and cognitive incapacity and define a strict framework for involuntary hospitality admission. Legislation can also ensure the quality of the provided services and prohibit any form of violence, harassment, exploitation and discrimination within the institutions and the community. Some cruel, inhuman and irreversible medical procedures can be prohibited from practice, such as involuntary sterilization and psycho-surgery and a clear framework on the rights and obligations of the mental health specialists can be given (Bertolote, 2005.). If there are still many violations of the rights of the mentally ill and a mental health legislation can ensure their protection, is there a need for a mental health specific, UN Convention?
The UN Conventions tend to be quite general, in order to be inclusive and be able to be interpreted in many ways. This may be quite a problem, especially when there are many different cultural, social and political frameworks a state can use, within its national legislation. Moreover, not all countries are open for complaints by individuals under the human rights treaties they have signed and not all treaty body based complaint mechanisms have entered into force.
May the UN Conventions be legally binding for the accelerated states, but there is no legal punishment or any actual intervention. “Collective legitimization is an aspect of the verbal rather than the executive functioning of the United Nations, and in some sense it is a result of the Organization’s incapacity for decisive intervention in and control of international relations. One might argue that the United Nations has resorted to saying “thou should” because it is in no position to say “thou shalt” and to saying “thou may” because it cannot say “thou must”.” (Claude, 1966, p. 372).
On the other hand, it would be more efficient to focus and further support the peripheral legislation, such as the Council of Europe, the organization of American States, the African Union, the League of Arab States and the Association of Southeast Asian Nations. The most important characteristic these organizations have in common is the somewhat cultural relativity among their member states. Second and very crucial, they have courts. A regional perspective would allow cultural, linguistic and other barriers to furthering mental health to be identified and discussed, Moreover, there would be a better balance between the developed and developing countries, and as a result it would be able to mobilize diverse resources from each regional, civil society. All these peripheral actions can act as a catalyst for global action on the neglected area of mental health.
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